The root of the problem or vice versa…
24 June 2019
Endodontic treatment is an area of dentistry that enjoys more than its fair share of dentolegal risk. Dr Martin Foster, dentolegal consultant, looks how this risk can be managed and reduced.
In the league table of treatments giving rise to complaints and claims,endodontics is near the top of the leader board. There are various reasons for this.
First of all, endodontic treatment is inherently tricky. Even a straightforward case can have a variety of built-in risks and pitfalls to get in the way of an ideal outcome.
No two root systems are the same. Nor are two patients. Both can be unpredictable.
Another important factor is the operator. Historically, endodontic related cases tended to be associated with more recently qualified dentists. This could lead to an assumption that contributing factors – such as limited experience and over-enthusiasm – were resulting in treatment being embarked upon that had a poor prospect of a successful outcome from the start. However, more recently, there has been a trend that suggests the majority of cases actually involve more experienced dentists, so it is clearly not quite such a simple picture.
As well as frequency of complaints and claims, endodontic cases can potentially be costly to deal with. In many instances, the argument is put forward that the dentist was responsible for causing the need for treatment in the first place. From the patient’s perspective, the tooth was not painful until the filling was placed. Then, after having root canal treatment, the patient learned that further treatment was necessary (eg a crown, retreatment or even extraction and implant placement) all of which incurred an unexpected and unwelcome cost for the patient.
So how should dentolegal risk be reduced when dealing with endodontic treatment?
Some dentolegal risks develop before treatment even starts, so it is important that a thorough assessment of the case is made early on to prevent subsequent surprises for the patient or dentist.
Making a diagnosis and deciding upon root treatment in the absence of appropriate radiographs is asking for trouble. So is embarking upon a heroic quest to “save” a tooth of dubious prognosis. Also, protecting the patient from a full knowledge of the risks, potential outcomes and costs is a good way of making an enemy. Avoiding these common pitfalls makes a lot of sense: a structured approach to include appropriate special tests, a definitive diagnosis, restorability assessment and a demonstrable, valid consent process reflects good practice.
Some complications can arise despite the best efforts of the clinician. All dentists know that an endodontically-treated tooth is more brittle and liable to fracture. A dentolegal risk associated with this is the possibility of a coronal fracture between visits, which renders the tooth unrestorable. The patient needs to be forewarned of this potential complication to avoid the dentist being blamed for the loss of the tooth. All too many cases arise from the patient forming the view that he/she would still have the tooth if it had not been for the dentist messing up the treatment – particularly if the tooth was symptomless in the first place.
File fractures and perforations should not happen, but they do. Taking a careful approach will certainly lessen the clinical risk. Dentolegal risk can be reduced by warning the patient of the possibility of complications and their practical implications at the outset. Explaining something only after it happens is often seen as an excuse by a patient unexpectedly facing additional treatment costs.
The best dentolegal defence in cases involving hypochlorite accidents or the ingestion/inhalation of instruments or other objects is making sure these don’t happen.If they do, defence is… well actually, there is no defence.
After treatment, dentolegal risks still remain. These may originate from a patient disappointed to be having further problems, or surprised by an outcome that was not anticipated. Another source is from “second dentist” syndrome – when another clinician identifies a “problem” about which the patient was completely unaware. This may be an issue that was not picked up by the treating dentist. It may not actually be a problem at all but simply a matter of interpretation of a result. A good post-treatment radiograph can be a helpful defence against this dentolegal risk.
If there is a “sub-optimal” result, it is good to spot this at the time so that the situation can be clarified with the patient. Any appropriate steps can then be taken to remedy the problem or perhaps simply to keep the case under review. The main thing is that the patient is made aware of the situation. If on the other hand, the patient learns of an issue from a third party at a later date, it can be viewed as a more serious fault – or worse, a cover up.
Assessing any case before starting is the key to managing both clinical and dentolegal risk.
It is important not to take on cases beyond your expertise and to recognise your limitations. Risks can arise from being talked into treatment, wanting to be helpful, feeling sorry for patients, not being able to say no or not being able to admit to having concerns about the case.
Patients may present with a less than ideal root filling on a radiograph, but it is worth pausing before recommending re-treatment. Consider first if you can improve on the clinical outcome. Do you think treatment is necessary? Would the patient actually benefit? The position may be stable and symptomless. Remember, patients measure success as a tooth being retained in a functional condition with no symptoms.
A structured case assessment – taking into account clinical and patient factors – can be a very helpful way to avoid wandering into trouble and questioning what you have undertaken.One good example of a structured case assessment tool can be found on the website of the American Association of Endodontists.
A structured approach allows the clinician to categorise the difficulty of the case and to advise the patient accordingly. Managing expectations is an important part of reducing dentolegal risk, but you can only manage patients’ expectations if you have an idea of what to expect yourself.
• Assess the case and manage patient expectation.
• Give a clear explanation of what to expect with regards to outcomes, risks and costs and avoid surprises.
• Be realistic and avoid herodontics - know what is possible, when to say no and when to refer.
• Avoid too little rubber dam and too little control of hypochlorite.
• Check files and canals carefully - if there is a fracture or a perforation, you must be the first to know… and the patient must be told by you. A less than ideal outcome can be made worse if not noticed/acknowledged or appears to have been covered up.
• Try to avoid “second dentist syndrome”- know how to judge “success” in the work of others.